|Year : 2014 | Volume
| Issue : 2 | Page : 56-59
Management of ankyloglossia: Have lasers taken the sheen away from scalpel
K Butchi Babu1, Uday Kiran Uppada2, Pradeep Koppolu1, Ashank Mishra1, C Ravi Chandra3, Ruchi Pandey1
1 Consultant Periodontist, Hyderabad, Andhra Pradesh, India
2 Oral and Maxillofacial Surgeon, Hyderabad, Andhra Pradesh, India
3 Endodontist, FMS Dental Hospitals, Hyderabad, Andhra Pradesh, India
|Date of Web Publication||21-Nov-2014|
K Butchi Babu
FMS Dental Hospital, Road No 1, Phase 1, KPHB, Kukatpally, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Purpose of the Study: The aim was to evaluate the patient's perception of pain associated with phonation, deglutition, and normal function following a lingual frenectomy using a scalpel and laser. Materials and Methods: This study included two groups of patients of five subjects each who reported with difficulty in speaking and deglutition. Patients in Group I were treated using scalpel and those in Group II underwent laser (diode) frenectomy. All these patients are evaluated for postoperative pain on 1 st , 3 rd and 7 th day. Results: The intergroup comparison of mean visual analog scale (VAS) scores for pain in both the groups showed significant differences. The intragroup comparison of mean VAS scores for pain within the scalpel group did not show any significant difference between the 1 st and 3 rd day, however, when the mean VAS scores of the 7 th day were compared with those on the 1 st and 3 rd day, the difference was highly significant. The intragroup comparison of mean VAS scores for pain within the laser group among all the days showed a significant difference. Conclusion: The results of the present study results showed that the patient's perception of pain associated with tongue movements following lingual frenectomy with laser is lesser when compared with scalpel.
Keywords: Ankyloglossia, laser, lingual frenectomy, visual analog scale
|How to cite this article:|
Babu K B, Uppada UK, Koppolu P, Mishra A, Chandra C R, Pandey R. Management of ankyloglossia: Have lasers taken the sheen away from scalpel. J Dent Lasers 2014;8:56-9
|How to cite this URL:|
Babu K B, Uppada UK, Koppolu P, Mishra A, Chandra C R, Pandey R. Management of ankyloglossia: Have lasers taken the sheen away from scalpel. J Dent Lasers [serial online] 2014 [cited 2020 Apr 4];8:56-9. Available from: http://www.jdentlasers.org/text.asp?2014/8/2/56/145140
| Introduction|| |
Tongue is a vital structure in the oral cavity that plays a pivotal role in speech, swallowing and position of the teeth. Ankyloglossia is a rare congenital oral anomaly characterized by an abnormally short and thick lingual frenum that interferes with the normal movements of the tongue resulting in impairment of its physiological functions. Over the years, diversity prevailed pertaining to its significance and management.
A lingual frenulum is a small fold of mucous membrane extending from the floor of the mouth to the midline of the underside of the tongue.  This usually consists of mucosa, dense fibrous connective tissue, and occasionally, superior fibers of the genioglossus muscle. 
Ankyloglossia is generally encountered in patients who do not have any other associated congenital anomalies, but on occasions they may be seen associated with some syndromes like X-linked cleft palate syndrome and Kindler syndrome, Ehler Danlos syndrome, van der Woude syndrome and Opitz syndrome. ,, The prevalence of ankyloglossia reported in the literature varies from 0.1% to 10.7%. , It is more common in males, with a male to female ratio of 2.5:1.0.  It can be observed in neonates, children or adults, but surprisingly most people do not complain about their anatomical anomaly, although functional problems can be associated with tongue tie in different stages of life. 
Frenectomy, frenectomy and frenuloplasty are the various surgical options available to treat ankyloglossia. ,, Frenectomy is the most widely employed surgical technique for correction of ankyloglossia which can be accomplished with the help of a surgical blade, bipolar diathermy or lasers.  This study is intended to evaluate the patient's perception of pain associated with tongue movements following lingual frenectomy with the help of either a scalpel or a diode laser.
| Materials and Methods|| |
Ten healthy subjects were selected from our hospital outpatient department who primarily reported of restricted tongue movements, with difficulty in speech and swallowing. Clinical examination revealed a short lingual frenum with difficulty in protrusion confirming ankyloglossia. Only patients who fell into the Kotlow's Class IV ankyloglossia were included in this study.
Subjects were randomly divided into two groups. Group I included five patients who underwent lingual frenectomy using a scalpel while Group II included five patients who underwent laser assisted lingual frenectomy. After giving profound anesthesia (2% lignocaine), patients in Group I were treated with a conventional scalpel. The lingual frenum was clamped with a hemostat and the frenum was slowly released by excision along the sides of the hemostat. The wound was closed with interrupted suturing (3-0 Mersilk) as shown in [Figure 1].
|Figure 1: Scalpel assisted lingual frenectomy. (a) Preoperative picture showing ankyloglossia (b) intra operative picture showing release of ankyloglossia (c) intra operative picture showing placement of sutures following release of ankyloglossia (d) postoperative picture|
Click here to view
Patients in Group II underwent laser assisted lingual frenectomy. Few drops of local anesthesia were injected into the frenum. Adiode laser (810 nm wavelengths, PICASO, Denstply) was used for the procedure. An initiated tip of 300 m diameter at 0.7 W continuous mode was used in contact mode to excise the frenum as shown in [Figure 2]. Evaluation was done by protrusive movements of the tongue. Sutures were not p-laced. A laser bandage was created over the wound area by using a laser in a defocussed (non-contact) mode at 2 W.
|Figure 2: Laser assisted lingual frenectomy. (a) Preoperative picture showing ankyloglossia (b) intra operative picture showing release of ankyloglossia (c) intra operative picture shoeing that sutures are not required|
Click here to view
Postsurgically instructions were given, and the patients in both groups were prescribed analgesic for 3 days. They were periodically evaluated on 1 st , 3 rd and 7 th day for the perception of pain associated with the tongue movements using a visual analog scale (VAS) scale. Patients in Group I underwent suture removal 1 week postsurgery.
| Results|| |
Statistical analysis was performed using a statistical program for social sciences version 17.0. The statistical significance of data for all pain scores between the groups was determined by a paired t-test and intragroup comparison was determined by analysis of variance. Changes were considered not significant at the P > 0.05 levels and highly significant at P < 0.001 as shown in [Table 1] and [Table 2].
|Table 1: Intergroup comparison of VAS scores of pain (between groups comparison) |
Click here to view
|Table 2: Intragroup comparison of VAS scores of pain in scalpel and laser groups |
Click here to view
The intergroup comparison of mean VAS scores for pain in both the groups showed significant differences. Intragroup comparison of VAS scores for pain within the scalpel group did not show any significant difference between the 1 st and 3 rd day. However, when the mean VAS scores of the 7 th day were compared with those on the 1 st and 3 rd day, the difference was highly significant as shown in Graph 1. Intragroup comparison of pain scores in the laser group showed significant differences. The results of this study clearly showed that the patient's perception of pain associated with tongue movements following lingual frenectomy with the help of a laser was much less when compared with a scalpel.
| Discussion|| |
The exact etiopathogenesis of tongue-tie is unknown. Embryo logically, it is believed that during the 4 th week of gestation, the lingual frenulum serves as a guide for forward growth of the tongue. During the later stage of the gestation, as the tongue continues to develop, frenulum cells undergo apoptosis, retracting away from the tip of the tongue and increasing the tongue's mobility.  This condition is a result of a failure in cellular degeneration leading to a much longer anchor between the floor of the mouth and the tip of the tongue. 
Even though most of the patients who are clinically diagnosed to have ankyloglossia do not complain about their anatomical anomaly, the consequences of not treating ankyloglossia are reflecting in their function at different stages of life. Improper chewing and swallowing of food could lead to gastric distress and bloating, improper cleansing action of the tongue can also lead to dental caries, malocclusion due to tongue thrust and in infants it can lead to difficulty in breast feeding. ,, Ankyloglossia may contribute to anterior open bite due to inability to raise the tongue to the roof of the mouth, preventing the development of normal swallowing pattern.  It may also be associated with upward and forward displacement of epiglottis and larynx resulting in various degrees of dyspnea.  However, there is no consensus regarding the indications, timing or method of surgical repair for ankyloglossia.
Frenectomy is the most widely employed technique for correction of ankyloglossia, which can be accomplished with the help of a surgical blade, bipolar diathermy or lasers.  The problems incurred using scalpels are the close proximity of the ducts of the submandibular glands, coupled with a richly vascular floor of mouth and hypermobility of the tongue. , Conventional scalpel method of frenectomy is age old method and even though the literature is replete with evidence of achieving good results they have their own pitfalls. Primarily suturing on the ventral surface of the tongue following a scalpel frenectomy may occasionally cause blockage of Wharton's duct. Surgical manipulations on the ventral part of the tongue may also damage the lingual nerve and cause numbness of the tongue tip. These pose a surgical challenge to the operator. This urges the need to select an ideal surgical modality to accomplish a lingual frenectomy.
Diode lasers have a wide spectrum of clinical application in soft tissue surgeries since they have photothermal property, which leads to almost no bleeding and clear surgical field which is due to sealing of capillaries by protein denaturation and stimulation of clotting factor VII production.  The thermal effect of laser seals the capillaries and lymphatic's, which also reduce the postoperative bleeding and edema and therefore reduces the stress of giving sutures. 
An added advantage of lasers is that postsurgical pain perception is less since laser stimulates the production of ί-endorphins, which are considered as our body's natural pain killer, thus causing pain relief. It has a profound effect on C fibers leading to decreased activity of these fibers and altering the pain threshold.  Hence, this study was intended to evaluate the patient's perception of pain associated with tongue movements following lingual frenectomy with the help of a scalpel and laser. Pain perception was rated on a VAS scale on the 1 st , 3 rd and 7 th day of the procedure. These results that were tabulated in [Table 1] and [Table 2] are in agreement with other studies stating that the frenectomy with the help of a laser causes very minimal or no pain.
The results clearly show that laser has proved to be advantageous in reducing pain among individuals and above all the complications of the surgery can be avoided using the same. The findings in our study are in accordance with Aggarwal et al. proposed that the usage of lasers inhibits the conduction of nerve fibers. They suggested that the inhibition of nerve conduction caused by lasers was not because of a permanent damage caused to the nerve, but due to a reversible conformational change in the voltage-gated Na-K channels, similar to the action of local anesthetic agents. 
Secondary clinical effects associated with lasers are decrease in the levels of histamine, bradykinins and substance P, which reduces the inflammation. This minimizes the initial postoperative edema and discomfort during function though in our study no subjects reported with edema.  Histologically, laser wounds have been found to contain significantly lower number of myofibroblasts. This could be attributed to less wound contraction and scarring, and ultimately improved healing.
Laser assisted lingual frenectomy is easy to perform with excellent precision, less discomfort, and short healing time compared with the conventional scalpel technique. , On considering the following advantages of laser over scalpel frenectomy: (1) Efficient soft tissue cutting due to a clear operative field provided by achieving hemostasis; (2) eliminates the requirement of sutures; (3) less operating time; (4) brisk chance of postsurgical infection eliminating the need for postoperative antibiotics; (5) decreased wound contraction and scarring; we suggest laser as an ideal tool in the management of ankyloglossia.
| Conclusion|| |
Ankyloglossia is a relatively harmless condition whose treatment is relatively simple. This study throws light on the fact that diode lasers can be considered as a safe, effective, and efficient tool in the management of anatomical anomalies like ankyloglossia.
| References|| |
Bhat D, Suchetha A. Lingual frenectomy to treat ankyloglossia: A pre-prosthetic venture. Indian J Dent Adv 2010;2:282-90.
Hupp JR, Tucker MR, Ellis E. Contemporary Oral and Maxillofacial Surgery. 6 th
ed. Ch. 13, Elsevier, 2013. p. 222.
Suter VG, Bornstein MM. Ankyloglossia: Facts and myths in diagnosis and treatment. J Periodontol 2009;80:1204-19.
Chaubal TV, Dixit MB. Ankyloglossia and its management. J Indian Soc Periodontol 2011;15:270-2.
Prasad K Musale, Abhishek S Soni, Shoeb Mujawar, Iqbal Musani. Use of Nd: YAG laser in the treatment of ankyloglossia for pediatric patient. J Dent Lasers 2012;6:33-7.
Segal LM, Stephenson R, Dawes M, Feldman P. Prevalence, diagnosis, and treatment of ankyloglossia: Methodologic review. Can Fam Physician 2007;53:1027-33.
Rizwan Sanadi, Jayant Ambulgekar, Manan Doshi. Adieu to tongue tie - lingual frenectomy: A case report. Int Res J Pharm 2013;4:203-4.
Yogesh Doshia, Mona Shahb, Nikhil Khandgec, Ankit Sanghavi. Advantages of diode laser over surgical blade in management of ankyloglossia: A case report. J Oral Laser Appl 2010;10:165-9.
Fiorotti RC, Bertolini MM, Nicola JH, Nicola EM. Early lingual frenectomy assisted by CO2 laser helps prevention and treatment of functional alterations caused by ankyloglossia. Int J Orofacial Myology 2004;30:64-71.
Kotlow LA. Ankyloglossia (tongue-tie): A diagnostic and treatment quandary. Quintessence Int 1999;30:259-62.
Nevile B, Damm D, Allen C, Bouquot J. Developmental defects of the oral and maxillofacial region. In: Brad W Neville, Douglas D Damm, Carl M Allen, editor. Oral and Maxillofacial Pathology. 2 nd
ed. Philadelphia: Saunders; 2002. p. 1-48.
Mukai S, Mukai C, Asaoka K. Congenital ankyloglossia with deviation of the epiglottis and larynx: Symptoms and respiratory function in adults. Ann Otol Rhinol Laryngol 1993;102:620-4.
Snophia Suresh, Uma Sudhakar, Satyanarayana Merugu, Ranjit Kumar. Management of ankyloglossia by diode laser. J Interdiscip Dent 2012;2:215-7.
Ramanarayana Boyapati, Kiran K Reddy, Ramesh Babu Mutthineni, Srikanth Chintalapani. Comparison of diode lasers and surgical blade in the management of ankyloglossia: A case report. J Res Adv Dent 2014;3:44-8.
Walsh LJ. The current status of low level laser therapy in dentistry. Part 1. Soft tissue applications. Aust Dent J 1997;42:247-54.
Aggarwal H, Singh MP, Nahar P, Mathur H, Gv S. Efficacy of low-level laser therapy in treatment of recurrent aphthous ulcers-A sham controlled, Split Mouth Follow up study. J Clin Diagn Res 2014;8:218-21.
[Figure 1], [Figure 2]
[Table 1], [Table 2]